• tertiary prevention
• post-impact care
• trauma mortality
• disability

An analysis of Western European data suggests that the number of deaths attributable to trauma is in decline. There is an assumption that this fall in mortality is a direct consequence of improvements to the environment and, to a lesser extent, to changes in behaviour. Examples include initiatives that have been termed primary prevention such as traffic segregation and product design and those termed secondary prevention that include seat belts and helmet laws. However, the direct causal relationship between the introduction of such measures and subsequent change in the mortality rate is difficult to prove. The link with the changing patterns of disability is often even more elusive.

Closer examination of the available statistics indicates that this general trend towards fewer trauma deaths is not equally distributed across society. Mortality rates are falling more slowly in the young adult population and in deprived sections of the community. The effect of so-called host factors, that is pre-existing medical problems in those who are injured may, in part, explain this phenomenon. These host factors are, of course, particularly evident in the older population, but the well known association between deprivation and poor health means that the less privileged members of society of all ages are at double jeopardy. Their circumstances mean that they are more likely to sustain injury and the higher incidence of host factors coupled with inadequate support networks may impair their ability to make a satisfactory recovery.

There is, however, an additional problem affecting all sections of society. The size of the trauma epidemic is unnecessarily increased by the inefficiency of the health service's response. Pre-hospital care is improving but still of variable quality. Sometimes it is over zealous and frequently it is inadequately linked with the hospital phase of resuscitation. The concept of a trauma system is …